The swing states of Obamacare

Three states could have an outsize role in the success — or failure — of Obamacare.

California, Florida and Texas are home to more than one-third of the nation’s 46 million uninsured people. If the White House and its allies can’t convince large chunks of the uninsured in those three states to enroll in the Affordable Care Act’s new insurance exchanges, the administration could have a very hard time reaching its enrollment goals.

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“They have set out 7 million as their goal for enrollment in the first year and politically, getting close to 7 million is important,” said Caroline Pearson, vice president at Avalere Health. The enrollment period starts Oct. 1 and runs through March.

If Obamacare were a presidential race, these would be the “swing states.” Instead of a trove of voters, they’ve got millions of uninsured, and they’ll get high-profile administration visits, money, resources and loads of national press attention. And many of those uninsured are the “young invincibles” — the young healthy people who need to be brought into the new insurance markets to balance out the older and sicker customers.

“You look at the big states because that’s where the large numbers are,” said Joel Ario, former director of HHS’s office of insurance exchanges and now a managing director at Manatt Health Solutions.

President Barack Obama, Health and Human Services Secretary Kathleen Sebelius and outside groups such as Enroll America are already dedicating time and resources to playing big in Texas and Florida — the two states with the largest uninsured population and resistance from the local Republican-led governments.

Obama also gave one of his rare health care speeches on a June visit to California, which is the only one of the big three to embrace the health law and put significant money and energy of its own into outreach.

But just like in an election, there’s more than one way to do the math. These three “swing” states could have an outsize impact, but the White House and its allies are also putting energy into a second tier of high-impact states that have lots of uninsured people — and in most cases GOP governors who to varying degrees oppose the president’s health law. They include Arizona, Michigan, North Carolina, Ohio, New Jersey, Pennsylvania, Georgia and Illinois.

Enroll America, the nonprofit with close ties to the former Obama campaign operation, has hired staff to run a ground game on enrollment in these states, plus Florida and Texas. In most of them, the states refused to set up the exchanges or marketplaces — the online portals where people can sign up for insurance and qualify for tax subsidies — so the federal government had to step in.

CALIFORNIA

In California, which has more uninsured residents than any other state, the local government is doing the heavy lifting on Obamacare enrollment, supplemented by what’s expected to be occasional visits by the White House, like that June visit by Obama to tout California’s early success in carrying out the law.

The state government has already provided a staggering $43 million for enrollment outreach alone. The state’s exchange authority has gotten money to pay enrollers $58 for each successful application. And California began holding town hall events and other outreach on the ACA well before most other states.

Here, the law — and the president — is so popular among the uninsured that they train volunteers to call it Obamacare. In most other states, volunteers are taught to use less politically charged terms.

Because of the money and resources, California is frequently touted as the state that is implementing the Affordable Care Act most actively and aggressively. The stakes couldn’t be higher.